Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist | C52140 |
NPI | 1164963278 |
---|---|
Provider Name | Travis Petersen |
First Address | Greenville, NC 27834-7268 |
Second Address | Greenville, NC 27834-7268 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2017 |
Last Update Date | 09/03/2017 |